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0108-221 (PLBG)LICENSED CONTRACTOR DECLARATION I hereby affirm under penalty of perjury that I am licensed under provisions of Chapter 9 (commencing with Section 7000) of Division 3 of the Business and P.,ofessionals Code, and my, License is in full force and effect. License # Lic. Class Exp. Date C; V24002 Date 1 Z e'' Signature of Contractor OWNER -BUILDER DECLARATION I hereby affirm under penalty of perjury that I am exempt from the Contractor's License Law for the following reason: ( ) I, as owner of the property, or my employees with wages as their sole compensation, will do the work, and the structure is not intended or offered for sale (Sec. 7044, Business & Professionals Code). .( ) I, as owner of the property; am exciusiveiy contracting with licensed contractors to construct the project (Sec. 7044, Business & Professionals Code). () I am exempt under Section B&P.C. for this reason Date Signature of Owner WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ( ) I have and will maintain a certificate of consent to self -insure for workers' compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is'issued. ( ) I have and will maintain workers' compensation insurance, as required by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. My workers' compensation insurance carrier & policy no. are: Carrier Policy No. iSTA`A'E! FX1;kU 33'i3aaE•�1 (This section need not be completed if the permit valuation is for $100.00 or less). ( ) I certify that in the performance of the work for which this permit is issued, I shall not employ any person in any manner so as to become subject to the workers' compensation laws ofCalifornia, and agree that if I should become subject to the workers' compensation provisions.o„f;:Section 3700 of the Labor Code, I shall forthwith comply withathose.prowslons. n f / Date: Warning: Failure to secure Workers' Compensation coverage is unlawful and shall subject an employer to criminal penalties and civil fines up to $100,000, in addition to the cost of compensation, damages as provided for in Section 3706 of the Labor Code, interest and attorney's fees. IMPORTANT Application, is hereby made to the Director of Building and "Safety for a permit subject to the conditions and restrictions set forth on hisi application. 1'. Each person upon whose behalf this application is made & each person at whose request and for whose benefit work is performed under or pursuant t© any permit issued as a result of this applicaton agrees to, & shall, indemnify ; & hold harmless the City of La Quinta, its officers, agents and employees. , 2. Any permit issued as a result of this application becomes null and void if work is not commenced within 180 days from date of issuance of such permit, or cessation of work for 180 days will subject permit to cancellation. ' I certify that I have read this application and state that the above information is correct. I agree to comply with all City, and State laws relating to the building construction, and hereby authorize representatives of this City to enter upon , the above-mentioned property for, inspection purposes. Signature (Owner/Agent) i- E > - - Date.-'' i �_ UILDING PERMIT PERMIT" DATE VALUATION LOT i�� '�$, TRACT i. s2aw;m JOB SITE — APN '-'• ADDRESS 801-225 YmW?6A,IRDCV JsIVE •• OWNER CONTRACTOR / DESIGNER / EN (NEER I 80.22,5 WE°r_`i�PaD -110 DRIVE '84035 CAMON 1W. 3:EQX0, CA 92-201 LA QTHWEA PALM DRIM MT 01% 921,61 (7 6 OX,4 46 27%3 C'fPIA '342 USE OF PERMIT �C�l2t� £E�Bdl�C�23S7u�T�� atifgdc'td'�r'{df334.:'4'fi � , 96,Y A:M) COYOF GO.J!iSU.ilM'"�:'�OIN PLAIM.ING FES S"is''c�E•ft 10]aWU-419-000 530,00 r ?1�1' f,f<i "i.%� AULN : i'I.R4i� C�l:t?cx $30.00 p LESS �I-RAW"M $oXto AUG 2 3 2001 9MI.a PIMM � Y � EKS D NOW � 42rC 3 CITY OF LA 1?11!117" FINANCE uEr .. — s RECEIPT DATE 7 t BY �r: DATE FINALED INSPECTOR INSPECTION RECORD OPERATION DATE INSPECTOR OPERATION DATE INSPECTOR BUILDING APPROVALS MECHANICAL APPROVALS Set Backs Underground Ducts Forms & Footings Ducts Slab Grade Return Air Steel Combustion Air Roof Deck Exhaust Fans O.K. to Wrap F.A.U. Framing Compressor Insulation Vents Fireplace P.L. Grills Fireplace T.O. Fans & Controls Party Wall Insulation Condensate Lines Party Wall Firewall Gas Test Exterior Lath { Wast' Lines Drvwall - Int. Lath Water Piping Final COMMENTS: Final . ELECTRICAL APPROVALS Power Pole iround Conduit Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors TemD. Use of Power 0 Final Final POOLS - SPAS BLOCKWALL APPROVALS Steel Set Backs Electric Bond Footings Main Drain Bond Beam Approval to Cover Equipment Location Underground Electric Underground Plbg. Test Final Gas Piping PLUMBING APPROVALS Gas Test Electric Final { Wast' Lines Heater Final Water Piping Plumbing Final Plumb ^g Top Out Equipment Enclosure Shower Pans O.K. for Finish Plaster Sewer Lateral Sewer Connection orf_ I _,0P Pool Cover Encapsulation Gas Piping Gas Test Final COMMENTS: Final . ELECTRICAL APPROVALS Power Pole iround Conduit Low Voltage Wiring Fixtures Main Service Sub Panels Exterior Receptacles G.F.I. Smoke Detectors TemD. Use of Power 0 J h. }}:. 4''�� ! " ✓ y `moA: - �:;i�.�-c�. ter- FEES U.O.S. Rate _ :'....'45-500 Van Buren.. •• Indio, CA 92201..* (619) 347-2356 Due Paid '. Connection:.. x.. $ �?�);��. — _ $ L%` '� <' c� ❑ A Inspection: SEWER. CONNECTION PERMIT Principal Lateral ............ x $ _ . O Subsidiary Lateral ... = _ N?. 2001 El Saddle: ..... ..... ...... x. $ _ $ Disconnect: ... ..... New Construction... ❑ $ ❑ Addition: ...................... 'Addition.. .. ,. ❑ Annexation No. ❑ El �. Repair: ......................... Repair/Alteration ..........� , $E ❑ a" Parcel No.. $ Owner: i-1 U cic � e i C� Contractor $�: ' G, < Project Name: Receipt No.-. License No.: ` Project Address: g 0" °� a-��5 wair�� Phone No. Comments: �Pw� .r j/i-i �G CD ►nL"'� i O ✓l Applicant Signature: i' �- , �,- Lssuedby.^ - �:;i�.�-c�. Date: FEES U.O.S. Rate _ Total Due Paid '. Connection:.. x.. $ �?�);��. — _ $ L%` '� <' c� ❑ A Inspection: Principal Lateral ............ x $ _ $ O Subsidiary Lateral ... x $ _ $ El Saddle: ..... ..... ...... x. $ _ $ Disconnect: ... ..... .. x $ - $ ❑ Addition: ...................... x. '$ _ $ ❑ El �. Repair: ......................... x $ _ $E ❑ Other: x $ _ $ ❑El TOTAL FEES: $�: ' G, < Receipt No.-. ` INSPECTION RECORD 24 Hour Notice Required Prior to Inspection Date Inspection Comments Inspector > FINAL ACCEPTANCE All items for which this.was issued have been_ inspected and .meet Valley SF-.nitary District Standard Specifications.: Signed: Date: . WHITE — VSD CANARY — Annexation File PINK — Permitee EC SEWER SERVICE, INC. -COQ O o l0ng ORDER. . dba ECONO SEWER SERVICES . - P.O. BOX 192 •PALM DESERT, CA 92261 14980 (760) 346-2793 (760)'328-7760 FAX (760) 347-4978 DAT F RDER ` SERVICE CODE PHONE TECH N HELPER STARTING DATE.— TOTAL AMOUNT BILL TO TYPE OF WORK: ❑ CLEAN'DP_AINS ADDRESS ,, - [],OTHER, ` ❑ SEPTIC TANK CITY ❑ GREASE TRAP / ❑ SEEPAGE IPIT JOB NAME AND L CATION -+ ADDITIONAL WORK NEEDED: - - TANK SIZE: PAYMENT TERMS NET 10 DAYS FROM DATE OF SERVICE 1 VA PER MONTH CHARGE AFTER 30 DAYS. ` DESCRIPTION OF WORK: NDI ON OF TANK BEFORE SERVICE _ Good _ Trash & Garbage _ Excessive soap Fair _ Overflowing _ Sand Poor _ Blockage _ Repairs Needed Very Poor _ Odor Roots _ More frequen ervice needed one home E�otal amount due ❑ Total billing to Signature % / for above work: or be mailed after 1 here acknowledge the satisfactory completion completion r` of the above described work. of work 1 40 J TOTAL PUMP DISPOSAL FEE TOTAL LABOR ` EASE PAY FROM THIS INVOICE. NO STATEMENT WILL BE MAILED. TOTAL MATERIALS D OMPL TED tS WOR RED BY TOTAL AMOUNT $ - one home E�otal amount due ❑ Total billing to Signature % / for above work: or be mailed after 1 here acknowledge the satisfactory completion completion r` of the above described work. of work 1 40 J